By Dr Matt Clifford and Dr Will Ormiston, Interventional Radiologists, Nedlands
Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) in older men, significantly impacting quality of life.
While pharmacotherapy and surgical options such as transurethral resection of the prostate (TURP) remain mainstays of treatment, a growing cohort of patients are now turning toward minimally invasive, lower risk therapies that preserve sexual function and reduce recovery time.
Prostate artery embolisation (PAE) has emerged as an endovascular alternative. With mounting high-level evidence, including multiple randomised controlled trials and long-term follow-up studies, PAE is now formally included in the British National Institute for Health and Care Excellence (NICE) guidelines and the latest American Urological Association (AUA) guidelines for the management of BPH-related LUTS.
What is PAE?
PAE involves selective embolisation of the prostatic arteries via a femoral or radial arterial approach, using microspheres to induce ischemia, volume reduction, and ultimately symptom relief.
Unlike transurethral approaches, PAE is performed by interventional radiologists in an angiographic suite, typically as a day procedure without the need for general anaesthesia or catheterisation.
Appropriate patient selection is critical. PAE is best suited to men with moderate-to-severe LUTS due to BPH, particularly those wishing to avoid surgery or preserve ejaculatory function.
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PAE is also a valuable option for patients intolerant of medications or poor surgical candidates, including factors such as age, comorbidities, or anticoagulation status.
Severe pelvic atherosclerosis can complicate the embolisation procedure, so pre-procedural imaging may be warranted. Generally, patients with prostate volumes over 60cc achieve more predictable outcomes. There is no upper gland size limit for PAE efficacy; the bigger the better.
Where does PAE stand?
Over 20 prospective studies and six RCTs – including head-to-head comparisons with TURP, pharmacotherapy, and sham controls – have been published.
These consistently show a significant reduction in symptom burden, typically a 9-21 point drop in International Prostate Symptom Score, or IPSS, alongside improvements in quality of life and preservation of sexual function.
While PAE offers a less pronounced increase in maximum urinary flow rate compared to TURP – 5–7 mL/s vs 10–13 mL/s – it results in fewer adverse events, very low rates of urinary incontinence and better preservation of erectile and ejaculatory function.
Post-PAE MRI findings typically show a 20-30% reduction in central gland volume and decreased vascular enhancement.
Long-term data suggest durability, with symptomatic improvement maintained in most patients at five years. Recurrence requiring retreatment occurs in approximately 20% of cases.
Repeat PAE or transition to surgical management remains a viable pathway for these patients.
What the trials say
Recent high-quality randomised trials have challenged the traditional stepwise management of BPH, suggesting that PAE may be considered as an early intervention, even in treatment-naïve patients.
The PARTEM trial, a multicentre phase three French RCT, demonstrated that in men with BPH ≥50mL unresponsive to alpha-blocker monotherapy, PAE resulted in a significantly greater improvement in IPSS, quality of life, and erectile function compared to combined medical therapy with dutasteride and tamsulosin.
Similarly, the Australian P-EASY ADVANCE trial showed that in treatment-naïve men with moderate-to-severe LUTS and urodynamic obstruction, PAE provided superior symptom relief, improved urodynamic parameters, greater prostate volume reduction, and fewer sexual side effects than medication.
These results support considering PAE as a first-line, non-surgical alternative to long-term pharmacotherapy for appropriately selected men with symptomatic BPH.
PAE is generally well tolerated. The most common side effects are mild and self-limiting and include dysuria, urinary frequency, haematospermia and low-grade post-embolisation syndrome.
Major complications such as non-target embolisation to bladder, rectum, or penis are rare (<1%) when performed by experienced operators using cone-beam CT and advanced microcatheter techniques.
Radiation exposure is a frequently cited concern. Contemporary studies place the effective dose at the equivalent of two to three abdominal CT scans.
Adoption and access in Australia
While PAE is well established in Europe and North America, access in Australia remains variable, often dependent on local interventional radiology expertise and the strength of referral networks with GP’s and urologists.
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Local demand is growing for the procedure with most PAE centres around Australia seeing a rapid uptick in frequency, often with prior patients promoting the procedure in their social circles.
Interventional radiologists must work closely with GPs and urologists to identify suitable candidates, ensuring patients are informed of all available options and their respective trade-offs. PAE can offer patients a safe, effective and durable alternative to medication and surgery.
Key messages
- PAE is an evidence-based, minimally invasive treatment for BPH-related LUTS endorsed in British and American guidelines. Trials show it is more effective than medication in improving symptoms, quality of life, and urinary function in BPH
- Ideal candidates are men with large prostates and moderate-to-severe LUTS who are not surgical candidates, or seek to preserve sexual function
- Effective implementation requires close collaboration between GPs, urologists and interventional radiologists.
Author competing interests – nil
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